National PBM Monograph Template Rev20091005
New Molecular Entity (NME) Monograph
Immune Globulin Subcutaneous (Human) 20% Liquid (Hizentra®)
March 2011, Updated January 2012
VA Pharmacy Benefits Management Services,
Medical Advisory Panel, and VISN Pharmacist Executives
The purpose of VA PBM Services drug monographs is to provide a comprehensive drug review for making formulary decisions. These documents will be updated when new clinical data warrant additional formulary discussion. Documents will be placed in the Archive section when the information is deemed to be no longer current.
Executive Summary:1
Efficacy:
• SCIG is Immune Globulin Subcutaneous (SCIG) (Human), 20% Liquid indicated for the treatment of Primary Immunodeficiency Disease (PID).
• SCIG is administered as a subcutaneous infusion to be started one week after the patient’s last Immune Globulin Intravenous (Human) infusion (IVIG).
• The initial weekly dose of SCIG is calculated to achieve a systemic serum IgG exposure area under the concentration-time curve (AUC) not inferior to that of the previous IVIG treatment.
• The dose is adjusted over time based on clinical response and serum IgG trough levels, which should be measured after 2 to 3 months of treatment with SCIG with a goal level 1.3 times the trough level prior to the last IVIG treatment.
• The results of the Phase III study showed ideal efficacy of SCIG in patients with PID. No serious bacterial infections (SBIs), the primary endpoint, were observed during the entire study period, and the rate of any infections was very low, 2.76 infections per patient per year. Mean serum IgG trough levels during the efficacy period were maintained between 12.1 and 12.9 g/L, which is within the normal range for healthy individuals.
Safety:
• The most common adverse reactions include local injection site reactions (swelling, redness, heat, pain and itching), headache, vomiting, pain and fatigue.
• Contraindications: (1) anaphylactic or severe systemic reactions to human immune globulin or components of SCIG, such as polysorbate 80; (2) hyperprolinemia (SCIG contains the stabilizer L-proline); (3) IgA-deficient patients with antibodies against IgA and a history of hypersensitivity.
Introduction2-3
The purposes of this monograph are to: (1) evaluate the available evidence of safety, tolerability, efficacy, cost, and other pharmaceutical issues that would be relevant to evaluating SCIG for addition to the VA formulary; (2) define its role in therapy; and (3) identify parameters for its rational use in the VA.
Primary immunodeficiency disease is a broad term that describes several immunologic deficiencies, including common variable immunodeficiency (CVID), complement deficiency, IgG subclass deficiency, X-linked agammaglobulinemia (XLA), selective IgA deficiency, severe combined immunodeficiency, hyper IgM syndrome, chronic granulomatous disease (CGD), DiGeorge syndrome, and Wiskott-Aldrich syndrome.
It is estimated that there are approximately 250,000 individuals diagnosed with PID in the United States and that half a million Americans living with PID may be undiagnosed. People who live with PID are at risk for serious infections and may be managed with immune globulin therapy. According to the 2008 FDA bulletin, patients with PID may experience four or more SBIs per year without immunoglobulin replacement therapy.
Pharmacology/Pharmacokinetics1
Mechanism of Action
SCIG supplies a broad spectrum of opsonizing and neutralizing IgG antibodies against a wide variety of bacterial and viral agents. The exact mechanism of action is not clearly understood.
Pharmacokinetic data
The pharmacokinetics (PK) of SCIG was evaluated in a PK substudy of an efficacy and safety study that included patients with primary immunodeficiency. Nineteen subjects were previously treated with Immune Globulin Intravenous (Human), 10% Liquid, and were switched to weekly subcutaneous treatment with SCIG. After a 3-month wash-in/wash-out period, doses were adjusted individually with a goal of providing an AUC not inferior to that of a previous weekly equivalent IVIG dose. Table 1 summarizes PK parameters for subjects in the substudy following treatment with SCIG and IVIG.
Table 1. Pharmacokinetic Parameters of SCIG and IVIG
| |SCIG |IVIG* |
|Number of subjects |18 |18 |
|Dose* | | |
|Mean |228 mg/kg |152 mg/kg |
|Range |141-381mg/kg |86-254 mg/kg |
|IgG Peak Levels | | |
|Mean |1616 mg/dL |2564 mg/dL |
|Range |1090-2825mg/dL |2046-3456 mg/dL |
|IgG Trough Levels | | |
|Mean |1448 mg/dL |1127 mg/dL |
|Range |952-2623mg/dL |702-1810 mg/dL |
|AUC | | |
|Mean |10560 day x mg/dL |10320 day x mg/dL |
|Range |7210-18670 day x mg/dL |8051-15530 day x mg/dL |
*For IVIG – weekly equivalent dose
AUC – standardized to a 7-day period
Summary of PK findings:
• The average dose adjustment for SCIG was 153% (range: 126-187%) of the previous weekly-equivalent IVIG dose.
• After 12 weeks of treatment with SCIG at the individualized dose, the final steady-state AUC determinations were made in 18 of the 19 subjects completing the wash-in/wash-out period.
o Mean ratio of steady state AUCs (standardized to a weekly treatment period) for SCIG vs. IVIG treatment was 1.002 (range: 0.77-1.20) with a 90% confidence limit of 0.951 to 1.055 for the 18 subjects.
• IgG trough levels during treatment with SCIG were 1.3 times higher than the preceding trough levels during treatment with IVIG.
o This calculated SCIG:IVIG ratio of 1.3 (+/- 15% of this value, or +/- 0.2) can be used to assess dosing with SCIG by assuming a steady-state target IgG trough level will be in range of 1.1 to 1.5 times the previous steady-state trough levels with IVIG.
o Clinical response should be the primary consideration in dose adjustment.
• While the trough levels with SCIG are generally higher, the peak serum levels were shown to be lower than those achieved with IVIG.
• In contrast to IVIG administered every 3 to 4 weeks, weekly subcutaneous administration results in relatively stable steady-state serum IgG levels. Peak serum IgG levels were observed after a mean of 2.9 days (range: 0-7 days) in the 18 patients treated with SCIG.
• Other pharmacokinetic data, including Vd and T1/2, were not reported in the substudy. The half-life of immunoglobulin varies greatly according to preparation, administration site, and patient.
FDA Approved Indication(s) and Off-label Uses
SCIG is FDA-approved for the treatment of primary immunodeficiency disease. The clinical trial that led to FDA-approval included patients with Common Variable Immunodeficiency (CVID) and X-Linked Agammaglobulinemia (XLA).
Potential off-label uses include:
– Autoimmune hemolytic anemia
– Autoimmune neutropenia
– Bone marrow transplant; adjunct
– Cytomegalovirus infection; treatment and prophylaxis
– Dermatomyositis, systemic
– Guillain-Barre syndrome
– HIV infection
– Myasthenia gravis
– Pemphigus vulgaris
– Renal transplant rejection
– Respiratory syncytial virus infection
– Toxic shock syndrome
– Transplant of kidney, pre-transplant desensitization of highly sensitized patients
– Uveitis
Current VA National Formulary Alternatives
Immune globulin, Injectable Solution
On April 4, 2011, CSL Behring announced its intention to discontinue production of Vivaglobulin®, which was a SCIG (Human), 16% Liquid. The company recommends transitioning patients to SCIG (Human), 20% Liquid (Hizentra®).
Dosage and Administration1
Dosage
• Subcutaneous immune globulin (SCIG) should be administered on a weekly basis.
• To be started one week after the patient’s last Immune Globulin Intravenous (Human) infusion (IVIG).
• Initial weekly dose of SCIG is calculated to achieve a systemic serum IgG exposure (area under the concentration-time curve (AUC) not inferior to that of the previous IVIG treatment):
1.53 x previous IVIG dose (grams)
No. of weeks between IVIG doses
• To convert the dose from grams to milliliters, multiply the dose (in grams) by 5.
• Adjust the dose over time based on trough levels. The patient’s clinical response should be the primary consideration in dose adjustment.
o To determine if a dose adjustment may be considered, measure the patient’s serum IgG trough level 2 to 3 months after switching from IVIG to Subcutaneous immune globulin.
o The target serum IgG trough level on weekly SCIG treatment is projected to be 1.3 +/- 0.2 times (i.e., between 1.1 and 1.5 times) the last trough level.
o To adjust the dose based on trough levels, calculate the difference (in mg/dL) of the patient’s serum IgG trough level from the target IgG trough level (1.3 times the last IVIG trough level). Then find this difference in Table 2 and the corresponding amount (in mL) by which to increase or decrease the weekly dose based on the patient’s body weight.
Table 2. Adjustment (+/- mL) of the Weekly SCIG Dose Based on the Difference (+/- mg/dL) From the Target Serum IgG Trough Level
|Difference from target IgG|Body Weight (kg) |
|trough level (mg/dL) | |
| |10 |
|50 |0 |1 |
|SBIs [upper 99% CI] – primary endpoint |0 (0) |0 (0) [0.132] a |
|Infection episodes (non-serious) [95% CIs] |31 (81.6) |96 (2.76) [2.235-3.370]a |
|Days missed from work/school |12 (31.6) |71 (2.06) [N/A] b |
|Days hospitalized due to infection |1 (2.6) |71 (0.2) [N/A] b |
|Days with antibiotics for infection prophylaxis or treatment |27 (71.1) |1,688 (48.5) [N/A] a |
a Total number of days in the study N=12,697
b total number of days from patient diaries N=12,605
No SBIs were observed in both the mITT or ITT populations in this study. Overall, mean serum IgG trough levels in the efficacy period were maintained between 12.1 and 12.9 g/L.
For further details on the efficacy results of the clinical trials, refer to
Appendix: Clinical Trials (page 12).
Adverse Events (Safety Data)4
Deaths and Other Serious Adverse Events (Sentinel Events)
No deaths or serious adverse events occurred during the study.
Table 4. Most Common ADEs (Experienced by >5 patients with PID; ITT Population)
| |All events |Temporally associated (72 hr) |
|Adverse Event | | |
| |No. (%) of patients |No. (rate) of events |No. (%) of patients |No. (rate) of events |
| |(n=49) |(n=2,264) |(n=49) |(n=2,264) |
|Any AE |49 (100) |1,749 (0.773) |49 (100) |1,566 (0.692) |
|Injection site reactions |49 (100) |1,314 (0.580) |49 (100) |1,298 (0.573) |
|Sinusitis |14 (28.6) |20 (0.009) |7 (14.3) |10 (0.004) |
|Headache |13 (26.5) |40 (0.018) |12 (24.5) |32 (0.014) |
|Nasopharyngitis |11 (22.4) |15 (0.007) |8 (16.3) |8 (0.004) |
|Cough |8 (16.3) |9 (0.004) |5 (10.2) |6 (0.003) |
|Diarrhea |7 (14.3) |8 (0.004) |5 (10.2) |6 (0.003) |
|Bronchitis |6 (12.2) |9 (0.004) |5 (10.2) |6 (0.003) |
|Fatigue |6 (12.2) |6 (0.003) |4 (8.2) |4 (0.002) |
|Injection site bruising |5 (10.2) |19 (0.008) |5 (10.2) |18 (0.008) |
|Back pain |5 (10.2) |11 (0.005) |4 (8.2) |5 (0.002) |
|Acute sinusitis |5 (10.2) |7 (0.003) |4 (8.2) |5 (0.002) |
|Nausea |5 (10.2) |5 (0.002) |4 (8.2) |4 (0.002) |
|Abdominal pain upper |5 (10.2) |5 (0.002) |3 (6.1) |3 (0.001) |
|Upper resp. tract infection |5 (10.2) |6 (0.003) |3 (6.1) |3 (0.001) |
|Rash |5 (10.2) |7 (0.003) |2 (4.1) |3 (0.001) |
Table 5. Most Common Causally Related Adverse Events (ITT Population)
| |Infusion-related |Infusion-related and temporally associated |
|Adverse Event | |(72 hr) |
| |No. (%) of patients |No. (rate) of events |No. (%) of patients |No. (rate) of events |
| |(n=49) |(n=2,264) |(n=49) |(n=2,264) |
|Any AE |49 (100) |1,436 (0.634) |49 (100) |1,397 (0.617) |
|Injection site reactions |49 (100) |1,313 (0.580) |49 (100) |1,297 (0.573) |
|Headache |12 (24.5) |36 (0.016) |11 (22.4) |31 (0.014) |
|Injection site bruising |5 (10.2) |19 (0.008) |5 (10.2) |18 (0.008) |
|Vomiting |3 (6.1) |3 (0.001) |3 (6.1) |3 (0.001) |
|Pain |3 (6.1) |4 (0.002) |2 (4.1) |3 (0.001) |
|Fatigue |3 (6.1) |3 (0.001) |2 (4.1) |2 ( ................
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